Cardiac screening in school children: Combining auscultation and electrocardiography with a crowdsourcing model

BACKGROUND/PURPOSE

School-based cardiac screening is useful for identifying children and adolescents with a high risk of sudden cardiac death. However, because of challenges associated with cost, distance, and human resources, cardiac screening is not widely implemented, especially in rural areas with limited medical resources. This study aims to establish a cloud-based system suitable for mass cardiac screening of schoolchildren in rural areas with limited medical resources.

METHODS

Students from three schools were included. They or their guardians completed a simple questionnaire, administered in paper or electronic form. Heart sounds were recorded using an electronic stethoscope. Twelve-lead electrocardiograms (ECGs) were recorded and digitalized. The signals were transmitted through Bluetooth to a tablet computer and then uploaded to a cloud server over Wi-Fi. Crowdsourced pediatric cardiologists reviewed those data from a web-based platform and provided remote consultation. In cases in which abnormal heart sounds or ECGs were noted, the students were referred to the hospital for further evaluation.

RESULTS

A total of 1004 students were enrolled in this study. Of the 138 students referred, 62 were diagnosed as having an abnormal heart condition and most had previously been undiagnosed. The interrater agreeability was high.

CONCLUSION

An innovative strategy combining a cloud-based cardiac screening system with remote consultation by crowdsourced experts was established. This system allows pediatric cardiologists to provide consultation and make reliable diagnoses. Combined with crowdsourcing, the system constitutes a viable approach for mass cardiac screening in children and adolescents living in rural areas with insufficient medical resources.

Kawasaki disease in children with Bacillus Calmette-Guérin scar reactivity: Focus on coronary outcomes

BACKGROUND

/Purpose: Reactivity at the Bacillus Calmette-Guérin (BCG) scar is a pathognomonic feature of Kawasaki disease (KD). However, its value in predicting KD outcomes has not been emphasized. This study explored the clinical significance of BCG scar redness with respect to coronary artery outcomes.

METHODS

This retrospective study collected data on children with KD from 13 hospitals in Taiwan during 2019-2021. Children with KD were categorized into four groups based on the KD type and BCG scar reactivity. Risk factors of coronary artery abnormalities (CAA) were analyzed in all groups.

RESULTS

BCG scar redness occurred in 49% of 388 children with KD. BCG scar redness was associated with younger age, early intravenous immunoglobulin (IVIG) treatment, hypoalbuminemia, and CAA at the first echocardiogram (p < 0.01). BCG scar redness (RR 0.56) and pyuria (RR 2.61) were independent predictors of any CAA within 1 month (p < 0.05). Moreover, pyuria (RR 5.85, p < 0.05) in children with complete KD plus BCG scar redness was associated with CAA at 2-3 months; first IVIG resistance (RR 15.2) and neutrophil levels ≥80% (RR 8.37) in children with complete KD plus BCG scar non-redness were associated with CAA at 2-3 months (p < 0.05). We failed to detect any significant risk factors of CAA at 2-3 months in children with incomplete KD.

CONCLUSION

BCG scar reactivity contributes to diverse clinical features in KD. It can be effectively applied to determine the risk factors of any CAA within 1 month and CAA at 2-3 months.

Corrigendum: Helmet ventilation for pediatric patients during the COVID-19 pandemic: A narrative review

[This corrects the article DOI: 10.3389/fped.2022.839476.].

Development of cool and hot executive function deficit in children born very low birth weight with normal early development: A longitudinal cohort from aged 6 to 10

BACKGROUND

Studies showed preterm children born with very low birth weight (VLBW, <1500 g) are at risk for poorer executive functions (EFs). However, very little research has been reported longitudinally on the development of both cool and hot EFs deficits in preschool to school-age VLBW preterm children with normal early development.

AIMS

Present study aimed to investigate the development of cool and hot EFs in VLWB preterm children longitudinally.

METHODS

Forty preterm children born VLBW were followed up at ages 6, 8, and 10. Fifty term-born controls were recruited at each age stage. Cool EFs was assessed using backward digit span subtest of WISC-IV, Knox's Cube Test, Comprehensive Non-verbal Attention Test Battery (CNAT), Tower of London (ToL), Wisconsin Card Sorting Test (WCST), and hot EFs was assessed using Theory of Mind (ToM) and Delay of Gratification (GIFT) tasks.

RESULTS

The six-year-old VLBW preterm group showed significantly lower scores of planning in ToL, inhibition control in CNAT, and in both ToM and GIFT tasks. There is no significant difference in average cool and hot EFs between the eight and ten-year-old preterm group and the control group.

CONCLUSIONS

At six, VLBW preterm infants with normal early development have delayed cool and hot EFs development. Although the average performance of EFs can reach the level of the control group with age increasing to eight and ten years, there are still individual differences. It is recommended that more complete development indicators be established in the future, and early intervention should be made for VLBW premature children with delayed EFs.

Effects of 12-Week Progressive Sandbag Exercise Training on Glycemic Control and Muscle Strength in Patients with Type 2 Diabetes Mellitus Combined with Possible Sarcopenia

Patients with type 2 diabetes mellitus (T2DM) are at a three-fold increased risk of developing sarcopenia compared to those without diabetes. The objective of this study was to investigate whether an intervention involving progressive sandbag exercises is beneficial to patients with T2DM and possible sarcopenia in terms of enhancing muscle strength and controlling blood sugar levels. Forty patients with T2DM and possible sarcopenia (age > 50 years) were recruited and randomly divided into resistance training and control groups. Resistance exercises for the upper and lower extremities were performed using sandbags (0.5 kg at the beginning to 1 kg after 1 month). Patients in the control group were asked to maintain their usual daily lifestyle. After 12 weeks, the training group were significant better than the control group in terms of glycosylated hemoglobin, the five times sit-to-stand test, skeletal muscle mass and calf circumference, and the physiological domain of the World Health Organization Quality of Life Questionnaire. In conclusion, these simple home exercises are beneficial to patients with T2DM combined with possible sarcopenia. This approach can assist patients in controlling their levels of glycosylated hemoglobin as well as improve physical fitness and quality of life.

Body composition and pelvic fat distribution are associated with prostate cancer aggressiveness and can predict biochemical recurrence

This study evaluated the effect of body composition and pelvic fat distribution on the aggressiveness and prognosis of localized prostate cancer. This study included patients who underwent robot-assisted radical prostatectomy with positive surgical margins. Clinicodemographic data were collected from patients' medical reports. Pretreatment magnetic resonance images (MRI) obtained for cancer staging were reviewed by a single radiologist to calculate pelvic fat distribution and body composition. We correlated these body composition parameters with initial prostate-specific antigen (iPSA), Gleason score, extracapsular tumor extension, and biochemical recurrence (BCR)-free survival. The iPSA was significantly associated with body mass index (BMI; P = .027), pelvic fat volume (P = .004), and perirectal fat volume (P = .001), whereas the Gleason score was significantly associated with BMI only (P = .011). Tumor extracapsular extension was significantly associated with increased periprostatic fat volume (P = .047). Patients with less subcutaneous fat thickness (<2.4 cm) had significantly poor BCR-free survival (P = .039). Pelvic fat distribution, including pelvic fat volume, perirectal fat volume, and periprostatic fat volume, were significantly correlated with prostate cancer aggressiveness. Patients with less subcutaneous fat had an increased risk of BCR after radical prostatectomy.

Helmet Ventilation for Pediatric Patients During the COVID-19 Pandemic: A Narrative Review

The air dispersion of exhaled droplets from patients is currently considered a major route of coronavirus disease 2019 (COVID-19) transmission, the use of non-invasive ventilation (NIV) should be more cautiously employed during the COVID-19 pandemic. Recently, helmet ventilation has been identified as the optimal treatment for acute hypoxia respiratory failure caused by COVID-19 due to its ability to deliver NIV respiratory support with high tolerability, low air leakage, and improved seal integrity. In the present review, we provide an evidence-based overview of the use of helmet ventilation in children with respiratory failure.

High-flow nasal cannula in children with asthma exacerbation: A review of current evidence

Asthma is the commonest obstructive airway disease and the leading cause of morbidity in children. In the pediatric population, acute exacerbations of asthma are a frequent cause of presentations and hospital admissions. An acute asthma exacerbation is potentially life-threatening; it is predominantly treated using conventional oxygen therapy with bronchodilators and systemic corticosteroids. The treatment of those who do not respond to conventional therapy is escalated to noninvasive positive pressure ventilation (NIPPV) before invasive ventilation. Although NIPPV has demonstrated benefits and safety, it still has limitations such as treatment intolerance caused mainly by discomfort and complications. High-flow oxygen therapy administered through a nasal cannula (HFNC) provides respiratory support with adequate airway humidity and has demonstrated safety and benefits in clinical practice. In the present review, we discuss HFNC and variations in HFNC use, focusing on its feasibility and current evidence of using it on children with asthma exacerbations.

Impact of urine osmolality/urine sodium on the timing of diuretic phase and non-invasive ventilation support: Differences from late preterm to term neonates

BACKGROUND

Extracellular fluid retained in the lungs lead to respiratory distress in both late preterm (LP) and term neonates. The relationship between urine parameters toward the diuresis and the duration of ventilation postnatally is unknown. To find the correlation between the diuretic phase with urine parameters in the first 4 days after birth and the duration of non-invasive ventilation (NIV).

METHODS

Serial measurements of urine osmolality (Uosm), urine sodium (U_Na), and urine output (U/O) in neonates were collected at 5 time periods (T1:0-12 postnatal hours, T2:12-24 postnatal hours, T3:24-48 postnatal hours, T4:48-72 postnatal hours, T5:72-96 postnatal hours) were recorded. The correlations were analyzed in late preterm and term neonates.

RESULTS

Ninety-seven neonates were included. Negative correlation between Uosm and U/O were observed. LP neonates (n=26) and term neonates (n=71) had differences with Uosm at T2, U_Na at T4, T5, and U/O at T2, T3. Factors of U/O < 1 ml/kg/hr at T1 (odds ratio (OR) = 20.0; 95% confidence interval (CI) 1.796-222.776; p = 0.015) or Uosm > 273 mOsm/L at T1 (OR = 9.0; 95% CI 1.031-78.574; p = 0.047) in LP neonates and U_Na > 26.5 mEq/L at T5 (OR = 23.625; 95% CI 2.683-79.276; p < 0.01) in term neonates were associated with prolonged NIV use (> 120 hours).

CONCLUSION

We speculate the significant correlation between Uosm/U_Na and the diuretic phase. The LP neonates acquire earlier diuretic phase than the term neonates. The Uosm/U_Na in the first few postnatal days had the correlation with the duration of NIV support.

The Role of Heated Humidified High-flow Nasal Cannula as Noninvasive Respiratory Support in Neonates

Recently, heated humidified high-flow nasal cannula (HHHFNC) has been introduced and applied as a noninvasive respiratory support in neonates. Although HHHFNC is widely used in neonates presenting with respiratory distress, the efficiency and safety when compared with nasal continuous positive airway pressure or noninvasive positive pressure ventilation are still controversial. This review aims to evaluate the performance and applications of HHHFNC in neonates.

[Historical review on obstructive sleep apnea in children]

An historical review on the discoveries on pediatric obstructive sleep apnea syndrome and sleep-disordered breathing is outlined. Starting with the description by Dickens of "Joe" the obese, snoring and sleepy individual, the authors trace more than 50 years of questions and research starting with the lean adult to the child and from the recognition of obstructive sleep apnea syndrome to the outline of upper-airway resistance syndrome. The pathophysiological knowledge on sleep-disordered breathing has evolved over time, as have treatment approaches in children, from tracheostomy to positive-airway-pressure therapy, to adenotonsillectomy with and without orthodontic treatments to oral-facial myofunctional therapy. Co-morbidities of sleep-disordered breathing are multiple, involving cognition, behavioral, and mood disorders, cardiovascular impairment, etc. There have been many advances in a short time due to the investigation of OSAS, but many questions still need responses.

Long-term efficacy of miglustat in paediatric patients with Niemann-Pick disease type C

Niemann-Pick disease type C (NP-C) is a rare inherited neurovisceral disease characterized by progressive neurological manifestations. Oral miglustat was first approved for the treatment of children and adults with NP-C in Europe in 2009. There are still relatively few published data on the long-term efficacy and safety of miglustat in patients with NP-C in clinical practice. We report the effects of up to 6 years of treatment with miglustat 100 mg t.i.d. in five children. Overall, 3/5 patients displayed progressive dysphagia before starting miglustat, and 4/5 showed marked cognitive and/or motor impairment. The mean age at treatment start was 11.6 years, and the median (range) duration of therapy so far is 4 (4.1 to 6.1) years. No treatment dose alterations were required, but therapy was interrupted for 1-3 months at least once in all patients due to supply issues. Swallowing function was stabilised during miglustat therapy, with no significant increase in Han dysphagia scale or aspiration-penetration index scores among four evaluable patients (p > 0.05). Scores on the mini-mental state examination indicated an improvement in cognitive function during the first 3-6 months of miglustat therapy, followed by stabilisation up to 5 years. Ambulatory function remained stable for at least the first 2 years of treatment in most patients, but there was a trend towards deterioration thereafter, possibly related to treatment interruptions. The safety/tolerability profile of miglustat was similar to previous clinical studies, although reports of gastrointestinal disturbances were rare. Overall, miglustat appeared to stabilise key parameters of neurological disease progression.

Stabilization of blood methylmalonic acid level in methylmalonic acidemia after liver transplantation

Methylmalonic acidemia with complete mutase deficiency (mut(0) type) is an inborn error of metabolism with high mortality and morbidity. LT has been suggested to be a solution to this disease, but elevation of urinary and blood MMA was still observed after LT. In this study, we measured dry blood spot MMA and its precursor propionyl-carnitine (C3-carnitine) for mut(0) patients. The results revealed that when C3-carnitine rose during metabolic stress, MMA rose exponentially (up to 1000 micromol/L) in patients who did not undergo LT. In patients who underwent LT, MMA rose to 100-200 micromol/L when C3-carnitine reached 10-20 micromol/L. However, when C3-carnitine rose further to 40-50 micromol/L, MMA levels just stayed put. Therefore, LT stabilized blood MMA level, though there might be a threshold for blood MMA clearance by the donor liver. This finding should be critical to understand the long-term outcome for LT in methylmalonic acidemia.

Recombinant human acid [alpha]-glucosidase: major clinical benefits in infantile-onset Pompe disease

BACKGROUND

Pompe disease is a progressive metabolic neuromuscular disorder resulting from deficiency of lysosomal acid alpha-glucosidase (GAA). Infantile-onset Pompe disease is characterized by cardiomyopathy, respiratory and skeletal muscle weakness, and early death. The safety and efficacy of recombinant human (rh) GAA were evaluated in 18 patients with rapidly progressing infantile-onset Pompe disease.

METHODS

Patients were diagnosed at 6 months of age and younger and exhibited severe GAA deficiency and cardiomyopathy. Patients received IV infusions of rhGAA at 20 mg/kg (n = 9) or 40 mg/kg (n = 9) every other week. Analyses were performed 52 weeks after the last patient was randomized to treatment.

RESULTS

All patients (100%) survived to 18 months of age. A Cox proportional hazards analysis demonstrated that treatment reduced the risk of death by 99%, reduced the risk of death or invasive ventilation by 92%, and reduced the risk of death or any type of ventilation by 88%, as compared to an untreated historical control group. There was no clear advantage of the 40-mg/kg dose with regard to efficacy. Eleven of the 18 patients experienced 164 infusion-associated reactions; all were mild or moderate in intensity.

CONCLUSIONS

Recombinant human acid alpha-glucosidase is safe and effective for treatment of infantile-onset Pompe disease. Eleven patients experienced adverse events related to treatment, but none discontinued. The young age at which these patients initiated therapy may have contributed to their improved response compared to previous trials with recombinant human acid alpha-glucosidase in which patients were older.

Treatment and outcome of Taiwanese patients with 6-pyruvoyltetrahydropterin synthase gene mutations

Ten cases of tetrahydrobiopterin (BH4) deficiency were identified in 1,337,490 newborns screened in a Chinese population in Taiwan. The high incidence of BH4 deficiency in the Taiwanese population may be explained by a founder effect, since all of the patients revealed 6-pyruvoyltetrahydropterin synthase gene mutations, and grouping N52S and P87S mutations together constituted 88.9% of the disease alleles. BH4 supplementation with restriction of high-protein foods gave control of plasma phenylalanine within normal range, and levodopa itself prevented seizure. However, the average intelligence quotient (IQ) score of these patients was only 76 +/- 14 (56-98). Statistically, the age of starting medication, including 5-hydroxytryptophan (5-HTP), was inversely correlated to IQ scores of these patients. We suggest the combination of BH4, levodopa and 5-HTP as the standard protocol to commence the treatment of BH4 deficiency as early as possible, although prenatal brain damage could have existed.

Determination of the relationship between T cell responsiveness and the number of MHC-peptide complexes using specific monoclonal antibodies

We describe the generation of three mAbs that recognize the complex of the class II MHC molecule IEk bound to a peptide derived from the carboxyl terminus of moth cytochrome c (residues 95-103). Reactivities of these mAbs are sensitive to single alterations in the sequence of both helices of the MHC molecule and to the bound peptide. The epitopes of these reagents are distinct but overlap substantially. One of these mAbs specifically blocks lymphokine release by T cells responsive to this complex but not others. We have used another to examine how the number of complexes on an APC is related to its ability to stimulate T cells. We find that 200-400 complexes per cell are necessary and sufficient to induce a degree of stimulation, whereas maximum stimulation is achieved only if more than 5000 complexes are present. The analysis indicates that T cell activation is a stochastic process.

Nephrotic syndrome in a bone marrow transplant recipient without chronic graft-versus-host disease

A 5-year-old girl developed severe proteinuria and microscopic hematuria 17 months after allogeneic bone marrow transplantation (BMT) for chronic myeloid leukemia. These nephrotic symptoms occurred during cyclosporin tapering, in the absence of other signs of chronic graft-versus-host disease (GVHD). A renal biopsy revealed focal segmental glomerulosclerosis. After methylprednisolone therapy, the proteinuria gradually decreased. The altered or disordered immune regulation that occurred after BMT may have resulted in the development of nephrotic syndrome.

Suspended rice particles for cultivation of Monascus purpureus in a tower-type bioreactor

Cultivation of Monascus purpureus (CCRC 31615) for the production of natural pigments was investigated. Traditionally, Monascus species were grown on rice by solid-state culture. For large-scale cultivation, solid-state cultures were associated with some problems such as contamination and scale-up. By using submerged cultures with rice particles, a stirred-tank fermentor was not suitable for submerged cultures as the impeller tended to break the particles into small pieces. A conventional bubble column was also unsuitable as its mixing capability was poor. In the present study, a modified bubble column with wire-mesh draft tubes was employed for the cultivation of M. purpureus. The proposed column had a shorter mixing time and a higher oxygen transfer rate relative to the conventional bubble column. The production of pigments using the proposed column was up to 80% higher than that achieved using the conventional bubble column.

Congenital intracranial teratoma

Congenital intracranial teratoma is a rare disease. A fetus with a congenital intracranial teratoma presenting with a disproportionately enlarged head at 27 weeks gestation is presented. Prenatal ultrasonography and fetal magnetic resonance imaging demonstrate a huge, heterogenous intracranial mass in the left supratentorial region, with the left cerebral hemisphere being compressed and flattened. The infant died of respiratory failure within 24 hours of birth at 28 weeks gestation. On postmortem examination the histologic report revealed an immature teratoma. Fetal MRI is helpful in the prenatal diagnosis and evaluation of intracranial tumor.

Modeling the effects of sodium chloride on degradation of chloramphenicol in aquaculture pond sediment

Sodium chloride was added to aquaculture pond sediment to determine effects of different salinities on degradation of chloramphenicol (CM). In this experiment, freshwater (0 ppt salinity) eel pond sediment slurries (10% w/v) were amended with sodium chloride to obtain salinities of 12, 24 and 36 ppt. There were no significant differences in sorption rate either between aerobic and anaerobic conditions or among various salinities. Degradation of CM fitted well to the decaying exponential curve. The degradation rates under anaerobic conditions were significantly greater than those under aerobic conditions. As salinity increased, the degradation rates decreased under both aerobic and anaerobic conditions. The differences in degradation rates either between aerobic and anaerobic conditions or among various salinities were attributed to the effects of microbial activities under different environments.

Typhoid fever presenting as infection-associated hemophagocytic syndrome: report of one case

This report describes a 13-year-old boy who had high fever with severe pancytopenia and acute psychosis as initial presentation. Bone marrow examination was compatible with infection-associated hemophagocytic syndrome (IAHS). Blood culture showed no growth of bacteria while the culture of bone marrow yielded Salmonella typhi. The clinical condition stabilized shortly after the use of ceftriaxone. This case illustrates that typhoid fever must be included in the differential diagnosis of IAHS. In cases with IAHS, bacterial culture as well as morphological study of bone marrow is necessary for the evaluation of etiological agent and to avoid injudicious use of chemotherapy.

The specificity of a weak gamma delta TCR interaction can be modulated by the glycosylation of the ligand

The gamma delta T cell clone LBK5 recognizes the MHC molecule IEk. Here, we demonstrate that the affinity of this interaction is weaker than those typically reported for alpha beta TCRs that recognize peptide/MHC complexes. Consistent with our previous finding that peptide bound to the IE molecule does not confer specificity, we show that the entire epitope for LBK5 is contained within the polypeptide chains of the molecule, centered around the polymorphic residues 67 and 70 of the IE beta-chain. However, LBK5 recognition is profoundly influenced by the N-linked glycosylation at residue 82 of the IE alpha-chain. Since infected, stressed, or transformed cells often change the posttranslational modifications of their surface glycoproteins, this finding suggests a new way in which gamma delta T cell Ag recognition can be regulated.

Visualizing lymphocyte recognition

Studies of T cell recognition have entered new territory now that some of the basic issues of genetics, biochemistry and structure have been addressed, at least in outline form. In the present work, the focus is on a new aspect of T cell recognition that goes beyond classical biochemistry to ask, how to TCR and other cell surface molecules cooperate to initiate and control recognition?'

Differential effect of B lymphocyte-induced maturation protein (Blimp-1) expression on cell fate during B cell development

The B lymphocyte-induced maturation protein (Blimp-1) upregulates the expression of syndecan-1 and J chain and represses that of c-myc. We have transfected Blimp-1 into two sublines of the BCL1 B cell lymphoma that represent distinct stages of B cell development in secondary lymphoid tissues. After interleukin (IL)-2 and IL-5 stimulation, the BCL1 3B3 cells differentiate into centrocyte-like cells, whereas the BCL1 5B1b cells blast and appear to be blocked at the centroblast stage. This blasting effect and the increase in IgM secretion that follows it can be blocked by a dominant negative form of Blimp-1. At the same time, the ectopic expression of Blimp-1 in these partially activated cells induces an apoptotic response that also can be suppressed by the same dominant negative protein. A similar effect was noticed when Blimp-1 was expressed in the mature L10A and the immature WEHI-231 lines, indicating this may be a general effect at earlier stages of the B cell development, and distinct from the ability of Blimp-1 to induce maturation in late stages of differentiation. Truncation mutants indicate that the induction of the apoptotic response relies mainly on 69 amino acids within Blimp-1's proline-rich domain. We propose that Blimp-1 expression defines a checkpoint beyond which fully activated B cells proceed to the plasma cell stage, whereas immature and partially activated cells are eliminated at this point.

Induction of rapid T cell activation and tolerance by systemic presentation of an orally administered antigen

To understand how orally introduced antigen regulates peripheral immune responses, we fed cytochrome c protein to mice transgenic for the beta chain of a cytochrome c-specific TCR and followed the antigen-specific T cell responses with a cyt c/I-Ek tetramer staining reagent. We find that within 6 hr of cytochrome c administration, antigen-specific systemic T cell activation is induced, and spleen cells gain the ability to stimulate cytochrome c-specific T cell responses. Feeding multiple low doses of cytochrome c down-regulates the systemic immune response, which can be correlated with a reduction of antigen-specific T cells and not with immune deviation. These results suggest that systemic distribution of antigen contributes significantly to oral tolerance induction.

CD4 augments the response of a T cell to agonist but not to antagonist ligands

The recognition of peptide variants by the T cell receptor (TCR) has revealed a wide range of possible responses. Here, using a series of CD4+ and CD4- variants of the same T cell hybridoma, we find that while the expression of CD4 converts weak agonists into full agonists, none of the antagonist peptides are efficiently recognized as agonists. Furthermore, in antagonist assays, little difference can be seen in the response of CD4+ and CD4- T cells. Together with previous work showing a marked difference in stability between TCR binding to agonist versus antagonist ligands, these data suggest that CD4 engagement occurs after a TCR-peptide/MHC complex has formed and that it requires a certain minimal half-life of the ternary complex to be fully engaged in signaling.

Early biochemical signals arise from low affinity TCR-ligand reactions at the cell-cell interface

The kinetics of acid release by a mixture of T cells and antigen presenting cells were measured with a microphysiometer during a brief exposure to antigenic peptides. We find that some of the early biochemical events that lead to cellular proliferation cause a specific increase in the rate of acid release. The duration of this increase in acid release reflects the life-time of the peptide-MHC complexes. Peptides that form long-lived complexes produce a response that is stable for more than an hour. Serial TCR engagement is suggested by the observation that the amplitude of this stable response can be rapidly shifted up or down with additional agonist peptide or with antibodies that block T cell receptor binding. Cells briefly exposed to a peptide that forms short-lived peptide-MHC complexes produce a response that decays rapidly as peptide is washed away. A quantitative analysis of the kinetics of this decay in acidification demonstrates that intercellular TCR-ligand reactions are rapid, reversible, and of low apparent affinity with < 20% of peptide-MHC ligand bound to a TCR at any one time. These results demonstrate that the fraction of peptide-MHC ligands bound to TCRs at the cell-cell interface is no higher than anticipated from the affinities observed in solution for isolated TCRs and ligands.

Recognition by gamma/delta T cells

In contrast with the study of alpha beta T cells, that of gamma delta T cells is relatively recent and stems from the discovery of their rearranged genes, rather than from any knowledge of their biological function. Thus, experiments designed to characterize their specificity and function have drawn heavily on our knowledge of alpha beta T cells. During the past few years, many studies, especially with mice lacking either alpha beta or gamma delta T cells, have demonstrated that gamma delta T cells can contribute to immune competence, but they do so in a way that is distinct from alpha beta T cells. It is also evident that gamma delta T cells may not recognize antigen the same way as do alpha beta T cells. Analysis of three protein antigens-the murine MHC class II IEk, the nonclassical MHC T10/T22, and the Herpes virus glycoprotein gI-indicates that gamma delta T cell recognition does not require antigen processing and that the proteins are recognized directly. In all three cases, recognition by these T cell clones involves neither peptides bound to these proteins nor peptides derived from them. Moreover, a group of small phosphate-containing nonpeptide compounds derived from mycobacterial extracts has been found to stimulate a major population of human peripheral gamma delta T cells in a T cell receptor (TCR)-dependent manner. This indicates that gamma delta T cells can respond to ligands that are different from those of alpha beta T cells. Analysis of complementarity determining region (CDR3) length distributions of gamma and delta chains indicates that they are more similar to those of immunoglobulins than to TCR alpha and beta. This further supports the idea that gamma delta and alpha beta T cells recognize antigens differently and suggests that gamma delta T cells may be more like immunoglobulins in their recognition properties. gamma delta T cells share many cell surface proteins with alpha beta T cells and are able to secrete lymphokines and express cytolytic activities in response to antigenic stimulation. These, together with the results cited above, indicate that gamma delta T cells can mediate cellular immune functions without a requirement for antigen processing. Thus, pathogens, damaged tissues, or even B and T cells can be recognized directly, and cellular immune responses can be initiated without a requirement for antigen degradation or specialized antigen-presenting cells. This would give gamma delta T cells greater flexibility than the more classical type of alpha beta T cell-mediated cellular immunity.

Gamma delta T cells. T cells with B-cell-like recognition properties

Recent results suggest there are fundamental differences in antigen recognition by alpha beta and gamma delta T-cell receptors, which might underlie possible differences in function between these two types of T cell.

Functional expression and recognition of nonclassical MHC class I T10b is not peptide-dependent

Studies of classical and nonclassical MHC class I molecules have shown that unique peptides are associated and functionally recognized by alloreactive T cells. We have recently shown that an alloreactive TCR-gamma delta cell recognizes a nonclassical MHC molecule, T10b. However, T cell recognition of this glycoprotein did not appear to require typical peptide recognition based on studies using transporter-defective mutant cell lines. In the current study, we have analyzed in detail, the role of peptide in T10b expression and recognition. The findings reveal that the recognition of the nonclassical MHC molecule by TCR-gamma delta cells is independent of species, tissue type, both the class I and class II Ag processing and presentation pathways, or the presence of peptides. In fact, biochemical analysis of the T10b chimeric molecule, T10b/Ld, transfected into CHO cells using radiolabeled [3H]leucine, HPLC, and mass spectrometry suggest that peptides are not associated with this nonclassical class I molecule. Therefore, some class I molecules, e.g., T10b, do not associate with polymorphic peptides typical of classical MHC class I molecules and can be expressed in the absence of peptides on the cell surface in a functionally active form.

Functional expression and recognition of nonclassical MHC class I T10b is not peptide-dependent

Studies of classical and nonclassical MHC class I molecules have shown that unique peptides are associated and functionally recognized by alloreactive T cells. We have recently shown that an alloreactive TCR-gamma delta cell recognizes a nonclassical MHC molecule, T10b. However, T cell recognition of this glycoprotein did not appear to require typical peptide recognition based on studies using transporter-defective mutant cell lines. In the current study, we have analyzed in detail, the role of peptide in T10b expression and recognition. The findings reveal that the recognition of the nonclassical MHC molecule by TCR-gamma delta cells is independent of species, tissue type, both the class I and class II Ag processing and presentation pathways, or the presence of peptides. In fact, biochemical analysis of the T10b chimeric molecule, T10b/Ld, transfected into CHO cells using radiolabeled [3H]leucine, HPLC, and mass spectrometry suggest that peptides are not associated with this nonclassical class I molecule. Therefore, some class I molecules, e.g., T10b, do not associate with polymorphic peptides typical of classical MHC class I molecules and can be expressed in the absence of peptides on the cell surface in a functionally active form.

T-cell receptor V-region usage and antigen specificity. The cytochrome c model system

Investigations of the I-Ek-restricted, cytochrome c-specific T-cell response in mice show that both T-cell receptor V alpha and V beta CDR3 residues and the use of particular V alpha s and V beta s are necessary for recognition. Data strongly suggest that specific CDR3 residues are important in contacting the peptide. Other experiments indicate that the requirement for V alpha:V beta conservation is not the result of strong TCR-->MHC interactions, as no correlation was found between V beta usage and changes in the alpha-helixes of the I-Ek molecule. It is also apparent that changes in V alpha or V beta usage could be elicited by changes in the side chain size of single amino acids of the antigenic peptides, suggesting that V alpha or V beta conservation is important for peptide recognition, either directly or indirectly. We also show that we can follow the cytochrome c response in vivo even in nontransgenic mice, solely by staining with anti-V region antibodies as well as mAbs directed at the activation markers CD44 and L-selectin.

The nature of major histocompatibility complex recognition by gamma delta T cells

Despite intensive efforts, the general rules for gamma delta T cell recognition remain undefined. Here, we take advantage of the detailed knowledge of the molecular structure and biosynthetic pathways of major histocompatibility complex (MHC) molecules to analyze the recognition properties of the gamma delta T cell clones LBK5 (specific for the class II MHC, IEk) and G8 (specific for the nonclassical class I MHC, TL10b). We find that the activation of these clones requires neither class I nor class II antigen-processing and that peptides do not confer specificity. Epitope mapping also shows that the topology of gamma delta T cell receptor interaction with the MHC is distinct from that of alpha beta T cells. These results suggest that the molecular nature of gamma delta T cell recognition is fundamentally different than that of alpha beta T cells.

CDR3 length in antigen-specific immune receptors

In both immunoglobulins (Ig) and T cell receptors (TCR), the rearrangement of V, D, and J region sequence elements during lymphocyte maturation creates an enormous degree of diversity in an area referred to as the complementarity determining region 3 (CDR3) loop. Variations in the particular V, D, and J elements used, precise points of recombination, and random nucleotide addition all lead to extensive length and sequence heterogeneity. CDR3 loops are often critical for antigen binding in Igs and appear to provide the principal peptide binding residues in TCRs. To better understand the physical and selective constraints on these sequences, we have compiled information on CDR3 size variation for Ig H, L (kappa and lambda) and TCR alpha, beta, gamma, and delta. Ig H and TCR delta CDR3s are the most variable in size and are significantly longer than L and gamma chains, respectively. In contrast, TCR alpha and beta chain distributions are highly constrained, with nearly identical average CDR3 lengths, and their length distributions are not altered by thymic selection. Perhaps most significantly, these CDR3 length profiles suggest that gamma/delta TCRs are more similar to Igs than to alpha/beta TCRs in their putative ligand binding region, and thus gamma/delta and alpha/beta T cells may have fundamentally different recognition properties.

How alpha beta T-cell receptors 'see' peptide/MHC complexes

Recent results have added new information to our understanding of alpha beta T-cell receptor mediated recognition. In particular, we find that the V(D)J junction or 'CDR3' portion of TCR alpha and beta seem most important in contacting peptides bound to MHC molecules, consistent with previous predictions. Surprisingly, these same CDR3-peptide contacts also appear to have a major influence on the TCR-MHC molecule interactions as well.

T cell receptor interaction with peptide/major histocompatibility complex (MHC) and superantigen/MHC ligands is dominated by antigen

While recent evidence strongly suggests that the third complementarity determining regions (CDR3s) of T cell receptors (TCRs) directly contact antigenic peptides bound to major histocompatibility complex (MHC) molecules, the nature of other TCR contact(s) is less clear. Here we probe the extent to which different antigens can affect this interaction by comparing the responses of T cells bearing structurally related TCRs to cytochrome c peptides and staphylococcal enterotoxin A (SEA) presented by 13 mutant antigen-presenting cell (APC) lines. Each APC expresses a class II MHC molecule (I-Ek) with a single substitution of an amino acid residue predicted to be located on the MHC alpha helices and to point "up" towards the TCR. We find that very limited changes (even a single amino acid) in either a CDR3 loop of the TCR or in a contact residue of the antigenic peptide can have a profound effect on relatively distant TCR/MHC interactions. The extent of these effects can be as great as that observed between T cells bearing entirely different TCRs and recognizing different peptides. We also find that superantigen presentation entails a distinct mode of TCR/MHC interaction compared with peptide presentation. These data suggest that TCR/MHC contacts can be made in a variety of ways between the same TCR and MHC, with the final configuration apparently dominated by the antigen. These observations suggest a molecular basis for recent reports in which either peptide analogues or superantigens trigger distinct pathways of T cell activation.

Development of gamma delta T-cell subsets from fetal hematopoietic stem cells

Hematopoietic stem cells (HSC) were isolated from mouse fetus, and their developmental potential was compared with adult HSC. Donor-derived V gamma 3+T cells were detected in fetal thymic lobes, repopulated in vitro with fetal liver HSC, but not in those with adult bone marrow HSC. Single clonogenic fetal HSC gave rise to thymic progeny that include V gamma 3+, other gamma delta+, and alpha beta+ T cells. No V gamma 3+ T cells were detected in adult thymus injected intrathymically with either fetal or adult HSC. These results support a hypothesis that only fetal HSC have the capacity to differentiate into V gamma 3+ T cells in the fetal thymic microenvironment, and that the developmental potential of HSC may change during ontogeny.

A gamma/delta cell receptor heterodimer induces the expression of CD4 and CD8 in thymocytes

CD4 and CD8 have been useful surface markers for alpha/beta T cell maturation. In an alpha/beta T cell receptor (TCR) transgenic SCID mice system, it has been shown that alpha/beta TCR alone is sufficient to induce CD4 and CD8 surface expression on thymic T cells. Although the late embryonic thymic gamma/delta T cells are predominately single and double positive, it has not been clear if gamma/delta TCR has a similar capacity. In this study, we show that when transgenes encoding the earliest embryonic gamma/delta TCR are coexpressed with the SCID defect, the gamma/delta transgenes promote the appearance of both the CD4-8- and CD4+8+ T cells in the thymus. Furthermore, the expression of CD4 and CD8 does not require continuous surface gamma/delta TCR expression. These results indicate that gamma/delta TCR alone can promote the CD4/8 surface expression, and may suggest a role for gamma/delta T cells in initiating normal thymic ontogeny.

Recognition of self antigens by skin-derived T cells with invariant gamma delta antigen receptors

Thy-1+ dendritic epidermal T cells (dECs) express invariant gamma delta antigen receptors and are found in intimate contact with keratinocytes in murine epidermis--thus raising the possibility that keratinocytes express a ligand for the antigen receptor of these T cells. Thy-1+ dECs were stimulated to produce lymphokines by interaction with keratinocytes in vitro. This stimulation was mediated through the dEC antigen receptor and did not appear to be restricted by the major histocompatibility complex. Thus, dECs can recognize self antigens and may participate in immune surveillance for cellular damage rather than for foreign antigens.

Expression of a fetal gamma delta T-cell receptor in adult mice triggers a non-MHC-linked form of selective depletion

Day 14 fetal thymocytes and adult dendritic epidermal T cells (dEC) of all mouse strains express a characteristic non-polymorphic gamma delta T-cell receptor which is rarely found in the adult thymus or lymph nodes. We have made transgenic mice expressing this particular set of receptors on T cells in C3H and C57BL/6 mice. In adult mice of the latter strain, a dramatic depletion of transgene expressing T cells occurs and this effect is primarily mediated by thymic radiosensitive cells. The depletion is genetically dominant but not MHC-linked with major factor(s) mapping to chromosome 18. Taken together, our results show that strain-specific developmental changes in the thymic environment may play a role in shaping the gamma delta TCR repertoire.